Download DRUGS TO AVOID IN THE ELDERLY A Summary on High Risk

DRUGS TO AVOID IN THE ELDERLY
A Summary on High Risk Medications
Gateway HealthSM is committed to providing safe, quality health care for our members. One of our
quality initiatives includes reducing the number of Medicare AssuredSM members age 65 or older
that may be taking a high risk medication. Our initiative is based off the American Geriatric
Society’s Beers Criteria, which was developed to assist healthcare providers with improving
medication safety in older adults. For a complete review of the Beers Criteria, please visit the
following website:
http://www.americangeriatrics.org/press/id:5907
Help us in our goal of providing high quality healthcare to our members by reviewing the following
chart. If any of your patients are 65 or older and currently taking one of the identified medications,
please review the AGS recommendations and rationale to prescribe a safer alternative. Avoiding
these medications can help reduce unwanted and potentially dangerous side effects for our
members.
Therapeutic Category / Drug(s)
Tertiary TCAs, alone or in
combination:
 Amitriptyline
 Doxepin (>6mg/day)
 Imipramine
Gateway Health, rev. 06/2016
Recommendation,
Rationale
Avoid.
Highly anticholinergic,
sedating, and cause
orthostatic hypotension; the
safety profile of low-dose
doxepin (≤6 mg/day) is
comparable to that of
placebo.
Alternatives
Depression
 SSRI
 SNRI
 Bupropion
 Viibryd
 Trazodone
 Mirtazapine
Insomnia
 Trazodone
 Rozerem
Migraine Prophylaxis
 Propranolol
 Topiramate
 Divalproex sodium
Neuropathic Pain
 Gabapentin
 Duloxetine
 Lyrica
Therapeutic Category / Drug(s)
Recommendation,
Rationale
Alternatives
For all indications a trial of
nortriptyline prior to use of
amitriptyline.
Anti-Parkinson’s agents:
 Benztropine
 Trihexyphenidyl
Avoid.
Not recommended for
prevention of extrapyramidal
symptoms with
antipsychotics; more
effective agents available for
treatment of Parkinson
disease.
Anticholinergic adverse
effects: difficulty urinating,
dizziness, blurry vision,
confusion.
Anticonvulsants:
 Carbamazepine
 Oxcarbazepine
Antidepressants:
 Paroxetine
Barbiturates:
 Butalbital/APAP/Caffeine
Caution advised due to
SIADH; patient should have
sodium levels checked upon
starting or changing dose
Avoid in med with BPH
Caution advised due to
anticholinergic effects,
sedation and orthostatic
hypotension
Avoid.
High rate of physical
dependence; tolerance to
sleep benefits; greater risk of
overdose at low dosages.
Gateway Health, rev. 06/2016
Parkinson’s disease
 Amantadine
 Apomorphine
 Carbidopa/levodopa
 Entacapone
 Pramipexole
 Ropinirole
 Selegiline
 Tolcapone
 Bromocriptine
Drug Induced EPS
 Discontinuation or dose
lowering of offended
drug recommended
 Lamotrigine
 Topiramate

Other SSRIs





Ibuprofen
Naproxen
Meloxicam
Tramadol
Acetaminophen
Therapeutic Category / Drug(s)
Skeletal muscle relaxants
 Chlorzoxazone
 Cyclobenzaprine
 Methocarbamol
 Orphenadrine
Therapeutic Category /
Drug(s)
First-generation antihistamines
as single agent, or part of
combination products:
 Cyproheptadine
 Hydroxyzine
 Brompheniramine
 Chlorpheniramine
 Clemastine
 Doxylamine
 Diphenhydramine*
Recommendation,
Rationale
Avoid.
Recommendation,
Rationale
Avoid.
Highly anticholinergic;
clearance reduced with
advanced age, and tolerance
develops when used as
hypnotic; increased risk of
confusion, dry mouth,
constipation, and other
anticholinergic
effects/toxicity.
Avoid.
In heart failure, no additional
benefit is associated with
higher dosages, and may
increase risk of toxicity;
Gateway Health, rev. 06/2016


Baclofen
Tizanidine
Most muscle relaxants are
poorly tolerated by older
adults because of
anticholinergic adverse
effects, sedation, and
increased risk of fractures;
effectiveness at dosages
tolerated by older adults is
questionable.
*Use of diphenhydramine in
special situations, such as
acute treatment of severe
allergic reaction, may be
appropriate.
Cardiovascular
 Digoxin >0.125 mg/day
Alternatives
Alternatives
Antihistamine
 Nasal saline
 Cetirizine liquid
 Levocetirizine
Migraine Prophylaxis
 Propranolol
 Timolol
 Topiramate
 Valproic acid
 Divalproex sodium
Anxiety
 Buspirone
 Citalopram
 Escitalopram
 Sertraline
Pruritis/Urticaria
 Cetirizine
 Levocetirizine
Nausea/Vomiting
 Ondansetron
 A lower dose of digoxin
(0.125mg) and
documentation of ongoing monitoring of
digoxin levels.
decreased renal clearance
may increase risk of toxicity.





Alpha blockers
Avoid.
Causes orthostatic
hypotension
Therapeutic Category /
Drug(s)
Estrogens, with or without
progestins
Oral Antidiabetics:
 Glyburide
 Chlorpropamide
Endocrine-Metabolic Agent
 Megestrol
Opioid analgesic
 Meperidine
Gateway Health, rev. 06/2016
Recommendation,
Rationale
Avoid oral and topical patch.
Topical vaginal cream:
acceptable to use low-dose
intravaginal estrogen for the
management of dyspareunia,
lower UTI, and other vaginal
symptoms.
Evidence of carcinogenic
potential (breast and
endometrium); lack of
cardioprotective effect and
cognitive protection in older
women. Evidence that
vaginal estrogens for
treatment of vaginal dryness
is safe and effective in
women with breast cancer,
especially at dosages of
estradiol <25mcg twice
weekly.
Avoid.
Thiazide diuretic
ACE inhibitor
ARB
Long acting CCB
Alternatives
Vasomotor symptoms due to
Menopause
 SSRIs
 Venlafaxine
Vaginal Atrophy due to
Menopause
 Estring
 Premarin vaginal cream
Osteoporosis Prevention
 Calcium
 Vitamin D
 Alendronate
 Raloxifene


Glipizide
Glimepiride



Evaluate risk vs. benefit
Continued monitoring
Patient counseling



Hydrocodone
Oxycodone
Morphine
Higher risk of severe
prolonged hypoglycemia in
older adults.
Increased risk of blood clots.
Does not have much of an
effect on weight gain.
Avoid.
Non-opioid analgesic
 Tramadol
Dihydropyridine Calcium
Channel Blocker
 Nifedipine, immediate
release
Anti-infective
 Nitrofurantoin
Not an effective oral
analgesic in dosages
commonly used; may cause
neurotoxicity, delirium,
cognitive impairment; safer
alternatives available.
Avoid in patients with a
seizure disorder or a
creatinine clearance <
30ml/min
Avoid.
Potential for hypotension;
risk of precipitating
myocardial ischemia
Avoid for long-term
suppression.
Potential for pulmonary
toxicity, liver toxicity and
peripheral neuropathy; safer
alternatives available.
Proton Pump Inhibitors
 Esomeprazole
 Lansoprazole
 Omeprazole
 Pantoprazole
Opioid agonist/antagonist
analgesic
 Pentazocine
Gateway Health, rev. 06/2016
Note: this medication has
been used safely and
effectively in patients with a
creatinine clearance as low as
30ml/min.
Avoid using for more than 8
weeks.
Potential for C. difficile
pseudomembranous colitis,
bone loss, fractures
Note: this does not apply to
patients with Barrett’s
Esophagus or those on
chronic NSAIDs
Avoid.
Opioid analgesic that causes
CNS adverse effects,
including confusion and
hallucinations, more


Fentanyl transdermal
Tramadol*







Hydrocodone
Oxycodone
Morphine
Generic NSAIDs
Nifedipine long acting
Amlodipine
Felodipine



Sulfamethoxazoletrimethoprim
Ciprofloxacin
Levofloxacin




Cimetidine
Famotidine
Ranitidine
Tizanidine






Tramadol
Generic NSAID
Voltaren gel
Generic Vicodin
Generic Vicoprofen
Celebrex
commonly than other narcotic
drugs; is also a mixed agonist
and antagonist; safer
alternatives available.
Antipsychotic
 Thioridazine
Antiplatelets, Anticoagulants:
 Ticlopidine
 Cilostazol
Avoid.
Highly anticholinergic and
greater risk of QT-interval
prolongation.
Avoid.




Abilify
Ziprasidone
Olanzapine
Risperidone

Clopidogrel

Warfarin



Low dose trazodone
Rozerem
Sleep hygiene education
Safer, effective alternatives
available.
May lower blood counts;
increased risk of infection.


Apixaban
Dabigatran
Nonbenzodiazepine hypnotics
 Zaleplon
 Zolpidem
Avoid.
Increase in bleeding risk
Avoid in patients > 75 yr old
or a creatinine clearance <
30ml/min
Avoid chronic use (>90
days).
Benzodiazepine-receptor
agonists that have adverse
events similar to those of
benzodiazepines in older
adults (e.g. delirium falls,
fractures); minimal
improvement in sleep latency
and duration; confusion, auto
accidents the day following a
dose.
Gateway Health, rev. 06/2016